Chronic prostatitis is one of the causes that elevate serum PSA. Treatment can normalize such elevated PSA. after treatment. However, the opportunities of potential prostate cancer still exist in patients with a decreased PSA level even also if PSA

I agree in general with the response of Dr. Elkoushy. This information may be complemented with the study of Shtricker et al: 

Int Braz J Urol. 2009 Sep-Oct;35(5):551-5; discussion 555-8.

PSA levels of 4.0 - 10 ng/mL and negative digital rectal examination. Antibiotic therapy versus immediate prostate biopsy.

Shtricker A1, Shefi S, Ringel A, Gillon G.

 Abstract

PURPOSE:

The management of mildly elevated (4.0-10.0 ng/ml) prostate specific antigen (PSA) is uncertain. Immediate prostate biopsy, antibiotic treatment, or short term monitoring PSA level for 1-3 months is still in controversy.

MATERIALS AND METHODS:

We conducted a retrospective chart review of patients in a large community practice (2003 - 2007) who had PSA levels between 4.0-10 ng/mL without any further evidence of infection. Data was gathered regarding patient's age, whether standard antibiotic therapy (10-14 days of ofloxacin or ciprofloxacin) had been administered before the second PSA measurement, results of a second PSA test performed at 1- to 2-month intervals, whether a prostate biopsy was performed and its result.

RESULTS:

One-hundred and thirty-five men met the study inclusion criteria with 65 (48.1%) having received antibiotics (group 1); the PSA levels decreased in 39 (60%) of which, sixteen underwent a biopsy which demonstrated prostate cancer in 4 (25%). Twenty-six (40%) patients of group 1 exhibited no decrease in PSA levels; seventeen of them underwent a biopsy that demonstrated cancer in 2 (12%). The other 70 (51.9%) patients were not treated with antibiotics (group 2); the PSA levels decreased in 42 (60%) of which, thirteen underwent a biopsy which demonstrated prostate cancer in 4 (31%). In the other 28 (40%) patients of group 2 there was no demonstrated decrease in PSA, nineteen of these subjects underwent a biopsy that demonstrated cancer in 8 (42%).

CONCLUSIONS:

There appears to be no advantage for administration of antibacterial therapy with initial PSA levels between 4-10 ng/mL without overt evidence of inflammation.

In order to minimize unnecessary biopsies, it is recommended not to biopsy a patient based on a single value of PSA. PSA can be repeated in 2-3 months and if still elevated a biopsy can be performed. If PSA returns to normal a biopsy can be avoided. If a patient is asymptomatic there's no need for antibiotic treatment in the interim, but if symptomatic, a urine culture and treatment according to the culture result can further decrease unnecesary biopsies by identification of patients with PSA elevation secondary to infection. A repeat PSA 6-8 weeks after completion of antibiotic treatment is recommended to verify the return of PSA to normal.

That is a very good question. I would prescribe antibiotics for 4- 8 weeks, then repeat PSA after 2 months of initial reading. If PSA value is still in grey zone, i would take a biopsy. If it drops to

PSA density, the ratio of free PSA to total PSA and PSA velocity are very usefull to select the best candidate for biopsy. So yes we should always repeat PSA. There is no role for antibiotic treatment in these patients except when you suspect a chroni bacterial prostatitis so a prostatic massage and a culture of prostatic secretion or post massage urinary drops are mandatory. At present, MRI had shown a clear advantage in these patient as a normal MRI avoid unnecessary biopsies.

I got two thums down and that hurts me. I believe in every word i wrote and that is my practice. I still agree with clinicians doing domething else. Data in literatures are even not solid and contradictory considering this point. So; every practice, even different, may be of value to our patients. Here are some literatures confirming what i previously mentioned.

1- Toktas G, Demiray M, Erkan E, Kocaaslan R, Yucetas U, Unluer SE. The effect of antibiotherapy on prostate-specific antigen levels and prostate biopsy results in patients with levels 2.5 to 10 ng/mL. J Endourol. 2013 Aug;27(8):1061-7. 

conclusion: Antibiotic treatment given to the patients with a PSA level between 2.5 and 10 ng/mL can be beneficial, before a decision for TRUS guided prostate biopsy, just in a limited subgroup, by reducing the PSA levels below the threshold value. 

2- Del Rosso A, Saldutto P, Di Pierro ED, Masciovecchio S, Galatioto GP, Vicentini C. [Impacts of antibiotic and anti-inflammatory therapy on serum prostate specific antigen in asymptomatic men: our experience]. Urologia. 2012 Dec 30;79 Suppl 19:37-40. 

conclusion: A combination of antibiotic and anti-inflammatory therapy seems to be a useful way to avoid unnecessary biopsies in patients with PSA range from 4 to 10 ng/ml.

3- Saribacak A, Yilmaz H, Ciftci S, Ustuner M, Ozkan L, Ozkan TA, Dillioglugil O. The role of empiric antibiotic treatment in preventing unnecessary prostate biopsies in asymptomatic patients with PSA levels between 4 and 10 ng/ml. Int J Clin Exp Med. 2014 Aug 15;7(8):2230-5.

conclusion: Empirical antibiotic treatment in asymptomatic patients with a PSA level 4-10 ng/ml and a normal DRE may be used to select prostate biopsy candidates.

Hi, dear all!

We've performed a small study on 193 patients, underwent prostatic biopsy (comparing responsiveness of different techniques of diagnosing PCa), and especially for elevated PSA levels in diagnosing PCa resulted in sensitivity of 0.98 and low specificity levels of 0.011 with LR+=0.99 and LR-=1.78 (OR=0.56). 

Here is an abstract of our investigation: https://www.researchgate.net/publication/265846683_AB129._Role_of_routine_examination_in_diagnose_of_prostate_cancer?ev=prf_pub

Article AB129. Role of routine examination in diagnose of prostate cancer

depending on free / total PSA can minimize the use of unnecessary prostatic biopsies especially if the value of total PSA was in the grey zone (4-10) ng/dl